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FA L L 2 0 1 4

For emergency medicine


and trauma professionals

In This Issue

1 Canthotomy and Cantholysis:


A Sight-Saving Intervention
3 Trauma Triage: The Right Patient
in the Right Hospital at the Right Time
4 Rebirth of the Tourniquet
7 CME Credit and Continuing Education

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TRAUMA

8 UPMC Medical Toxicology


Accreditation Statement : The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians. The University of Pittsburgh School of
Medicine designates this enduring material for a maximum of .5 AMA PRA Category 1 Credits. Each physician should only claim
credit commensurate with the extent of their participation in the activity. Other health care professionals are awarded .05 continuing
education units (CEU) which are equivalent to .5 contact hours.
Disclosures: Drs. Roxana Fu, Matthew R. Rosengart, Gregory A. Watson, and Evan Waxman have reported no relationships with
proprietary entities producing health care goods or services.
Instructions: To take the CME evaluation and receive credit, please visit https://cme.hs.pitt.edu/ISER (case-sensitive) and click on
Trauma and Emergency. If this is your first visit, you will need to create a free account.

Canthotomy and Cantholysis:


A Sight-Saving Intervention
by Roxana Fu, MD, and Evan Waxman, MD, PhD
Case
A 77-year-old woman was transferred from an outside hospital after sustaining a
ground-level mechanical fall. Her history is significant for anticoagulation with warfarin
for her bovine mitral valve replacement and recent hemispheric CVA. She is found to
have an intraparenchymal cerebral hemorrhage, right-sided orbital and zygomatic
fractures, and a supratherapeutic international normalized ratio of 3.7. She was given
two units of fresh frozen plasma and sent to UPMC for further management.
Upon questioning, she endorsed eye pain and decreased vision in her right eye. She was
only able to appreciate hand motion in her right eye. Examination of her pupils revealed a
right afferent pupillary defect (APD). Measurement of her intraocular pressure (IOP)
with a tonopen showed it was elevated in her right eye at 42 and normal in her left eye at
15. The remainder of her exam was significant for severe periorbital ecchymosis,
swelling, proptosis, and decreased abduction and adduction of her right eye.
Questions and Answers
How is the clinical diagnosis of an optic nerve compromising retrobulbar
hemorrhage made?
In the setting of trauma, decreased vision, proptosis, and decreased eye movement
should raise clinical suspicion for a retrobulbar hemorrhage causing optic neuropathy.
The aforementioned signs and symptoms should prompt further examination for an APD
and increased IOP. A CT scan demonstrating intraconal or extraconal hemorrhage is
helpful (Figures 1 and 2), but not necessary for diagnosis.
How would you manage this patient?
Once the diagnosis is made, an urgent orbital decompression is warranted by performing
a lateral canthotomy and cantholysis. Decreasing the intraorbital pressure, and
subsequently her IOP, restores normal circulation and prevents further vision loss. Visual
recovery is possible if orbital decompression is performed in a timely manner.
(Continued on Page 2)

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TR AUM A RO U N DS

Canthotomy and Cantholysis: A Sight-Saving Intervention (Continued from Page 1)


How else may patients with orbital compartment
syndrome present?
Outside of the setting of trauma, retrobulbar hemorrhage may
present spontaneously or iatrogenically after retrobulbar injection
of anesthesia and after surgical procedures such as orbital surgery,
blepharoplasty, or sinus surgery. Other nonhemorrhagic causes

Figure 1. Axial CT scan with right


extraconal orbital hemorrhage
(arrow) and marked proptosis.

Figure 2. Coronal CT scan with


right extraconal orbital
hemorrhage (arrow) and
complete opacification of the
maxillary sinus with blood.

include orbital cellulitis with or without abscess formation and


orbital apex syndrome in the setting of acute adjacent inflammatory
conditions (such as sinusitis without direct orbital involvement).
Discussion
Retrobulbar hemorrhage causing acute loss of vision is a rare
but serious and potentially blinding condition. Hemorrhage can
occur with minor trauma or in a delayed fashion. As ophthalmic
consultation may not be always readily available, physicians
triaging ocular trauma must familiarize themselves with the
needed examination and interventional skills.
Any trauma to the orbit can cause a retrobulbar hemorrhage.
Severe hemorrhage can cause orbital compartment syndrome,
like any space-occupying lesion. The orbit is enclosed by bony
anatomy, and any forward displacement is limited by the eyelid
apparatus and tethering of optic nerve to the globe. As intraorbital
pressure rises, ocular perfusion pressure decreases, leading
to ischemia. Multiple cranial nerves within the orbit may be
compromised, including the optic nerve and nerves controlling
eye movement. Animal studies have shown signs of ischemia after
100 minutes of central retinal artery occlusion; therefore, prompt
reversal of high intraorbital pressure is recommended.
The eyelids are fixated to the lateral rim by the lateral canthal
tendon. A lateral canthotomy is performed to expose the inferior
limb of the lateral canthal tendon (Figure 3). The inferior portion of
the lateral canthal tendon is palpable as a distinct corded entity
along the orbital rim, and the tendon is cut to ensure laxity of the
lower eyelid (Figure 4). The endpoint of the procedure is to allow
for additional forward movement of the intraorbital contents, and
less so for actual drainage of the hematoma.

Figure 3. Incision to perform a


lateral canthotomy: the lateral
canthus is cut approximately one
centimeter.

Figure 5. Incision of the inferior


limb of the lateral canthal tendon:
holding the lower eyelid anteriorly
with forceps, the cantholysis is
performed by strumming the
scissors along the inferior orbital
rim to find the tendon. After
palpating the tendon with the
scissors, the distinct corded entity
is cut.

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Figure 4. Lateral canthotomy.

Figure 6. Laxity of the lower eyelid


status post-canthotomy and
cantholysis.

While there are no large published case series guiding when


treatment should be initiated, the finding of an APD is diagnostic
of optic nerve compromise and should prompt urgent intervention
when accompanied by the aforementioned signs and symptoms.
In a darkened room, the pupils are examined with a bright light
source with the patient fixating at a distant target. The light is
repeatedly swung from the unaffected eye to the affected eye.
An APD is present if dilation, instead of constriction, is seen in the
affected eye in response to light.
While a multitude of adjunctive medical therapy has been
described, such as systemic and topical IOP lowering agents
and high-dose corticosteroids, these measures should not delay
surgical intervention. Some causes of retrobulbar hemorrhage can
be medically managed, but this should be reserved for cases with
close collaboration with ophthalmology. Further decompression of
the orbit in the operating room may be needed if surgical and
medical therapies fail to decrease the patients IOP.

UPMC

Our patient underwent a bedside lateral canthotomy and inferior


cantholysis within one hour of presentation and ultimately eight
hours after injury. Thirty minutes after the procedure, her IOP was
23. Three months after injury, the patients vision ultimately
recovered from hand motions vision to 20/50.
Roxana Fu is a third-year resident in ophthalmology at the
University of Pittsburgh School of Medicine. Evan (Jake)
Waxman is associate professor of ophthalmology and director
of both the Comprehensive Eye Service and the ophthalmology
residency program at UPMC. Contact Dr. Fu at fur@upmc.edu
and Dr. Waxman at waxmane@upmc.edu.
References
Bhatnagar A, Mayberry JC, Nirula R. Rib Fracture Fixation for Flail 1.
Scott M, Thomson A. Prompt Recognition and Treatment in Traumatic

Retro-Orbital Hematoma in Anticoagulated Elderly People Can Save Sight.


Journal of the American Geriatrics Society. 2009:57(3):568-9.
Hayreh SS, Jonas JB. Optic disk and retinal nerve fiber layer damage after
transient central retinal artery occlusion: an experimental study in rhesus
monkeys. Am J Ophthalmol. 2000:129(6):786-95.
Chen YA,Singhal D,Chen YR et al. Management of acute traumatic
retrobulbar haematomas: a 10-year retrospective review. J Plast Reconstr
Aesthet Surg. 2012:65(10):1325-30.
Goodall KL, Brahma A, Bates A et al. Lateral canthotomy and inferior
cantholysis: an effective method of urgent orbital decompression for sight
threatening acute retrobulbar haemorrhage. Injury. 1999:30(7):485-90.
McInnes G, Howes DW. Lateral canthotomy and cantholysis: A simple,
visionsaving procedure. Can J Emerg Med. 2002:(4):4952.
Brucoli M,Arcuri F,Giarda M. Surgical management of posttraumatic
intraorbital hematoma. Journal of Craniofacial Surgery. 2012:23(1):58-61.

Trauma Triage:
The Right Patient in the Right Hospital at the Right Time
by Matthew R. Rosengart, MD, MPH
Trauma affects one out of five Americans, requiring the expenditure
of $400 billion in direct medical costs each year. Regionalizationtiered levels of care that distribute the sickest patients to the highest
intensity hospitals (trauma centers) reduce mortality and morbidity1,2.
In fact, regionalization in trauma has become the standard of care,
and evidence suggests that inclusive trauma systems improve
outcomes by matching patient needs with institutional resources.
Ideally, therefore, patients with moderate to severe injuries should
receive care at trauma centers (TC), while those with minor injuries
should receive care at non-trauma centers (NTCs).
Thirty years ago, The American College of Surgeons Committee on
Trauma (ACS-COT) published guidelines for the triage of trauma
patients. Providers at outlying hospitals could use a simple algorithm
to identify patients with moderate to severe injuries, who would
benefit from transfer to a Level I/II trauma center. Emphasizing the
principle of triage, the proposed algorithm relied on information
gathered with a history, physical examination, chest x-ray and pelvis
x-ray. These well-established clinical practice guidelines specify
when to triage patients to specialty trauma centers (Figure 1).
Despite evidence that ACS-COT guidelines improve morbidity and
mortality, as well as concerted efforts to address known barriers to
compliance, some patients who meet criteria for transfer to a TC
remain at NTCs, referred to as under-triage3. Other studies have
reported a large proportion of severely injured patients with signs of
physiologic compromise (for example, hypotension and tachycardia)
undergo CT scan imaging at community hospitals prior to transfer
to a TC4. Interestingly, in this study pretransfer scans did not change

outcomes but did substantially increase system costs and


potentially delay access to a trauma center. Clearly the decision to
transfer a patient is complex and involves processing a far greater
amount of information than the mere application of validated
guidelines. Nonetheless, if outcomes depend on the speed with
which patients receive definitive care, it is imperative that we
identify areas of improvement in patient safety.
Regionalization depends on the ability of health care providers to
correctly identify patients who would benefit from transfer to a TC.
However, the clinical uncertainty associated with triage decisions
makes discrimination necessarily imperfect. Balancing pragmatism
with expert opinion regarding best practices, the ACS-COT has
recommended that mature trauma systems strive to achieve rates
of less than 5% under-triage (treatment of patients with moderate
to severe injuries at NTCs) and less than 50% over-triage
(treatment of patients with minor injuries at TCs). However, a
recent retrospective cohort analysis of trauma patients demonstrated
that current rates of secondary under-triage and over-triage do not
approach the recommendations5. In this study a 70% rate of
secondary under-triage suggested that physician discrimination
between patients with minor and moderate to severe injuries may
play a significant role in ongoing failures to accomplish regionalization5.
Furthermore, given the existing inability of physicians to discriminate
among patients with minor injuries and moderate to severe injuries
under conditions of uncertainty, the appropriate transfer of 95% of the
moderately to severely injured patients would require transfer of a
far high proportion of patients with minor injuries. Quality
(Continued on Page 6)

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TR AUM A RO U N DS

Rebirth of the Tourniquet


by Gregory A. Watson, MD, FACS
Despite ones feelings regarding armed conflict, one thing is
certain: every war has ushered in major medical advances. The
recent conflicts in both Iraq and Afghanistan are no exception.
We have seen major advances in transfusion medicine, hemorrhage
control, and battlefield resuscitation, just to name a few. One of
the hallmark injuries of these recent conflicts is blast injury, and
along with that we have seen a resurgence in the interest in and
use of tourniquets. As recent worldwide and domestic terroristic
events have proven, these injuries are no longer of interest only
to military surgeons but also to civilian first-responders and
trauma surgeons. In the following review, I will briefly discuss
the pathophysiology of blast injuries and the role of tourniquets
as a life- and potentially limb-saving intervention.
Blast injury represents the ultimate polytrauma (Figure 1). Four
major mechanisms are responsible for the spectrum of injuries
seen following a blast event. The primary blast injury results from
the blast wave itself. Stress and shear waves occur in tissues, and
these waves are reinforced and reflected at tissue density
interfaces. Gas-filled organs such as the lungs, ears, and intestines
are at particular risk. Common injuries include rupture of the
tympanic membranes, blast lung injury, eye injuries, concussions,
and hollow viscus injury. Secondary blast injury results from
missiles being propelled by the blast itself. These are classic
penetrating injuries, lacerations, and traumatic amputations.
Tertiary blast injury occurs as a result of the blast wave propelling
the individual into a surface or object, or as a result of a structure
falling on the victim. These cause typical blunt injuries as well as
crush injuries and compartment syndrome. Quaternary blast

Figure 1. Afghan soldier wounded by an improvised explosive device (IED).


Note the injuries to all four extremities, the application of tourniquets, and
the relatively uninjured torso (victim was wearing body armor).

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Figure 2. The Combat Application Tourniquet (C-A-T).

injury occurs as a result of other explosion-related injuries,


illnesses, or diseases. This may involve burns, inhalation of toxic
gases, or injury from other environmental contamination. A blast
event generally occurs in a populated area and mass-casualty
events are commonplace.
Primary, secondary, and tertiary blast injury can all result in severe
extremity injury, and the presence of a traumatic amputation has
been reported to be associated with a mortality rate of 50%.
Throughout history, the use of tourniquets has been both
championed and challenged and, until these recent conflicts, has
been very controversial (refer to an excellent review by Kragh et al.
for further information). However, data from the recent military
actions in both Iraq and Afghanistan clearly show that early and
appropriate tourniquet use saves lives. A 2008 study from a
combat support hospital (CSH) in Baghdad reported that survival
rates were higher with prehospital versus hospital use (89% and
78%), higher with use before shock onset versus after (96% and
4%), and higher with tourniquet use versus without (87% and
0%). Complications associated with tourniquet use were reported
to be infrequent and often minor and temporary.
All deploying U.S. servicepersons receive a Combat Application
Tourniquet (C-A-T; North American Rescue, Greer, S.C.) and are
instructed in its use (Figure 2). Furthermore, the Tactical Combat
Casualty Care (TCCC) guidelines call for early application of a
tourniquet in all cases of life-threatening extremity hemorrhage
and in cases of traumatic amputation(s). The tourniquet should be
applied two to three inches above the wound and tightened until
bleeding has stopped. If possible, confirm the absence of a distal
pulse as a venous tourniquet can exacerbate blood loss (Figure 3).

UPMC

If one tourniquet is ineffective, a second should be placed. The


time of tourniquet application should also be noted, and the
patient rapidly evacuated to a facility with immediate surgical
capabilities. Adherence to these guidelines clearly saves lives,
particularly if initiated before the onset of shock. In a study of
2,600 combat fatalities from Vietnam and a second study of 982
fatalities from the early years of the Afghanistan and Iraq conflicts,
the incidence of death from extremity hemorrhage was essentially
unchanged at 7.4% and 7.8%, respectively. However, a recent
review of 4,596 U.S. combat fatalities from 2001 to 2011 (after
widespread implementation of the TCCC guidelines) has shown
that the incidence of preventable death from extremity hemorrhage
has decreased to 2.6%.
Given these findings, tourniquets have been increasingly applied
in the civilian sector, though their use is still not widespread
(Figure 4). Though the types of injuries seen in combat should
be infrequently seen in the civilian setting, recent events such as
the Boston Marathon bombing suggest that we must be prepared
for these events. The Hartford Consensus, designed to increase
survivability in a mass-casualty event, stresses early hemorrhage
control and the use of tourniquets. The acronym THREAT is used
to describe the needed response in such events. T calls for threat
suppression, H for early hemorrhage control, RE for rapid extrication
to safety, A for assessment by medical providers, and T for
transport to definitive care. As far as hemorrhage control, early
application and use of tourniquets (and hemostatic dressings) by
tactical EMS and police officers is stressed. Recently, an expert
panel from the American College of Surgeons Committee on
Trauma EMS Committee published guidelines for prehospital hem
under specific clinical practice guidelines, that proper device
training be administered, and that education in its use be
expanded to include all prehospital personnel.

Figure 4. A young male patient who sustained an open femur fracture


with vascular injury following a motorcycle crash. A tourniquet was
applied by prehospital personnel.

In conclusion, blast injuries are no longer solely the concern of


military health care providers. Blast injuries, as well as certain
blunt and penetrating extremity injuries, have the potential for
significant blood loss. Early, effective hemorrhage control (before
the onset of shock) of the injured extremity clearly saves lives,
and the use of a tourniquet can be a valuable adjunct to first
responders. Though its application and effectiveness in the
military is well-established, the adoption of the tourniquet by
civilian prehospital personnel is not as widespread, though
guidelines and training continue to be developed and refined.
Gregory Watson is a trauma surgeon at UPMC Presbyterian and
also a Major in the Army Reserves who has deployed twice to
Afghanistan. Contact Dr. Watson at watsong@upmc.edu.
References
Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast injuries. Lancet.
2009 Aug 1;374(9687):405-15.
Kragh JF Jr, Swan KG, Smith DC, Mabry RL, Blackbourne LH. Historical
review of emergency tourniquet use to stop bleeding. Am J Surg. 2012
Feb;203(2):242-52.
Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB.
Practical use of emergency tourniquets to stop bleeding in major limb
trauma. J Trauma. 2008 Feb;64(2 Suppl):S38-49; discussion S49-50.
J.F. Kelly, A.E. Ritenour, D.F. McLaughlin, et al. Injury severity and causes of
death from Operation Iraqi Freedom and Operation Enduring Freedom:
2003-2004 versus 2006. J Trauma, 64 (2008), pp. S21S27.
B.J. Eastridge, R. Mabry, P. Seguin, et al. Death on the battlefield (20012011): implications for the future of combat casualty care. J Trauma Acute
Care Surg, 73 (2012), pp. S431S437

Figure 3. An Afghan soldier who sustained a gunshot wound to the distal


right thigh with a femoral vein injury. This picture depicts an incorrectly
applied venous tourniquet. Note the swelling of the right leg relative to
the left, the venous engorgement, and the sizeable hematoma of the
right thigh. This patient had intact distal pulses and should have had the
tourniquet tightened or a second one applied.

Jacobs LM, Wade DS, McSwain NE, Butler FK, Fabbri WP, Eastman AL,
Rotondo M, Sinclair J, Burns KJ. The Hartford Consensus: THREAT, a
medical disaster preparedness concept. J Am Coll Surg. 2013
Nov;217(5):947-53.
Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal
ND, Butler FK, Fallat M, Taillac P, White L, Salomone JP, Seifarth W,
Betzner MJ, Johannigman J, McSwain N Jr. An evidence-based prehospital
guideline for external hemorrhage control: American College of Surgeons
Committee on Trauma. Prehosp Emerg Care. 2014 Apr-Jun;18(2):163-73.

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TR AUM A RO U N DS

Trauma Triage (continued from Page 3)


improvement initiatives that merely raise the number of
transfers without reallocated resources would significantly
burden TCs. Thus, new educational strategies for helping
physicians discriminate among patients may be of
greater value.
At the physician level, existing quality improvement efforts
have focused on increasing knowledge, modifying attitudes,
and removing structural and economic barriers to transfer.
The extent to which cognitive aspects of physician
decisionmaking contribute to under-triage is unknown. In an
elegant study using signal detection theory, Mohan et al
identified several aspects of physician cognition that may
underlie either failure to or delays in transfer6. When
presented with case vignettes, most physicians demonstrated
limited perceptual sensitivity (the ability to discriminate
between patients who do and do not meet clinical practice
guidelines for transfer). Perceptual sensitivity reflects both
physicians knowledge of the clinical practice guidelines and
intuitive judgments (heuristics) about which patients meet
those guidelines. This study also identified a group of
physicians with a high decisional threshold (the tendency to
err on the side of false positive or false negative decisions)
for transfer. Decisional threshold reflects variables such as
attitudes towards the guidelines, incentives, and
organizational normal. Currently the ACS-COT uses ATLS,
an educational program that operationalizes the clinical
guidelines, as one of its primary tools to standardize the
treatment of trauma patients. Although most physicians in
this study had received ATLS certification, triage decisions
only weakly corresponded with ACS-COT criteria for transfer.
One possible explanation for variability in physician
performance is that volume influences outcomes. Physicians
who treated a greater number of patients with moderate to
severe injuries were more likely to triage them in accordance
with clinical practice guidelines7. That result echoes studies in
cancer, coronary artery disease, and critical care where
greater experience translates into better outcomes. However,
a recent study highlighted that patient volumes at nontrauma centers preclude physicians from obtaining significant
experience to triage patients with moderate to severe
injuries7. In that study, only one out of 50 patients presenting
after trauma, and one out of 1,000 patients presenting
overall, had an injury that met guidelines for transfer.
Moreover, patients who met the guidelines had a mean Injury
Severity Score (ISS) of 12, lower than the ACS-COT cutoff for
patients that warrant transfer regardless of their specific
injuries. This may contribute to the observation in that study

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UPMC

CME CREDIT AND CONTINUING EDUCATION


INSTRUCTIONS:
UPMC prints Trauma Rounds with an eye toward helping emergency
medicine professionals improve their preparedness and practice.
For Physicians, APPs, and Nurses
Please see front cover for details on CME credit from the
Accreditation Council for Continuing Medical Education (ACCME).

UPMC Prehospital Care also hosts numerous continuing education


classes in western Pennsylvania. For a full, up-to-date calendar and
online registration, visit UPMC.com/PrehospitalClasses.

Course Name

Date(s)

Contact

Advanced Trauma Life Support at


UPMC Presbyterian

Full Course: November 10-11, 2014


Recertification: November 11, 2014

Jennifer Maley
maleyjl@upmc.edu
412-647-8115

Advanced Burn Life Support at


UPMC Mercy

June 24, 2015

Noel Faust-Vislay
faustn@upmc.edu
412-232-7114

Save the Date:


2015 John M. Templeton, Jr. Pediatric
Trauma Symposium, Childrens Hospital
of Pittsburgh of UPMC

March 6-7, 2015

For more information, visit


www.chp.edu/CHP/trauma

that physicians discharged home one-third of patients the ACS-COT


would classify as having moderate to severe injuries.
Current quality improvement efforts in trauma triage assume that
the same barriers affect all physicians equally. However, the prior
studies that highlight individual performance differences suggest
the need for a more nuanced approach that targets the specific
impediments, whether they be perceptual sensitivity or decisional
threshold. Merely increasing the willingness to transfer patients may
increase over-triage and impose a burden on Level I TCs. An analysis
of triage patterns in Pennsylvania demonstrates that simply shifting
decisional thresholds to achieve ACS-COT targets for triage would
result in a five-fold increase in transfers to TCs5. Moreover, NTCs
would lose an important source of revenue and the opportunity to
provide care for patients in their community. It is clear that identifying
the critically injured patient that would benefit from higher-level care
and then deciding to transfer is difficult and complex. Further
research is required to determine how cognitive aspects of physician
decisionmaking affect the triage of patients in real practice, as well
as how best to intervene.
Matthew R. Rosengart is associate professor of surgery and
critical care medicine at UPMC. Contact Dr. Rosengart at
rosengartmr@upmc.edu.

For EMS Providers


To take a Pennsylvania Department of Health-accredited continuing
education test for one hour of credit for FR and EMT-B, EMT-P, and
PHRN, visit UPMC.com/TraumaRounds.

References
1.

Mohan, D., et al. Triage Patterns for Medicare Patients Presenting to


Nontrauma Hospitals With Moderate or Severe Injuries. Ann Surg,
2014.

2.

MacKenzie, E.J., et al. A national evaluation of the effect of


trauma-center care on mortality. N Engl J Med, 2006. 354(4): p.
366-78.

3.

Macias, C.A., et al. The effects of trauma center care, admission


volume, and surgical volume on paralysis after traumatic spinal cord
injury. Ann Surg, 2009. 249(1): p. 10-7.

4.

Mohan, D., et al. Determinants of compliance with transfer


guidelines for trauma patients: a retrospective analysis of CT scans
acquired prior to transfer to a Level I Trauma Center. Ann Surg, 2010.
251(5): p. 946-51.

5.

Mohan, D., et al. Assessing the feasibility of the American College of


Surgeons benchmarks for the triage of trauma patients. Arch Surg,
2011. 146(7): p. 786-92.

6.

Mohan, D., et al. Sources of non-compliance with clinical practice


guidelines in trauma triage: a decision science study. Implement Sci,
2012. 7: p. 103.

7.

Mohan, D., et al. Trauma triage in the emergency departments of


nontrauma centers: an analysis of individual physician caseload on
triage patterns. J Trauma Acute Care Surg, 2013. 74(6): p. 1541-7.

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UPMC MEDICAL TOXICOLOGY


The Importance of Diagnosing Alcohol Withdrawal Syndrome
Patients with alcohol dependency who are
admitted for routine surgery or following
traumatic injuries may develop alcohol
withdrawal syndrome (AWS) due to an acute
cessation of chronic ethanol intake. This
syndrome may complicate the hospital course
and, if undertreated, may increase morbidity
and mortality.
The clinical findings of AWS are systemic
manifestations of central nervous system
(CNS) hyperexcitation. Tachycardia,
hypertension, and tremor represent the
mildest form of AWS. Subjective complaints
include nausea, hallucinations, and anxiety.
Severe AWS may include seizures, though
they are often brief. These symptoms may be
confused for alternative diagnoses, especially
in the context of a patient with multiple
traumatic injuries. Therefore, keep a wide
differential diagnosis when evaluating a patient
with the above signs and symptoms.
The UPMC Division of Medical Toxicology,
part of the Department of Emergency
Medicine at the University of Pittsburgh
School of Medicine is the largest toxicology
program in western Pennsylvania, eastern
Ohio, and West Virginia. We also provide
consultations through the Pittsburgh Poison
Center, a nationally recognized regional poison
information control center.

Correctly diagnosing AWS is imperative for


initiating appropriate treatment. The treatment
is centered on early, aggressive front-loading
of benzodiazepines, primarily diazepam. We
recommend a symptom-triggered approach
with rapidly escalating doses every few
minutes until symptoms are controlled.
If this technique does not control symptoms,
consider alternative diagnoses or adding a
barbiturate, such as phenobarbital. UPMC
Medical Toxicology also recommends
intravenous sub-dissociative ketamine for
delirium tremens when benzodiazepines have
not adequately controlled symptoms or
normalized vital signs.
Contact the UPMC Division of Medical
Toxicology or the Pittsburgh Poison Center for
any additional treatment recommendations.

Trauma Rounds is published for


emergency medicine and trauma
professionals by UPMC.
Executive Editor
Andrew B. Peitzman, MD
Editor
Louis Alarcon, MD
Senior Outreach Liaison, Physician
Services Division
Cynthia A. Snyder, NREMT-P,
CCEMT-P, FP-C
Director, Prehospital Care
Myron Rickens, EMT-P
Managing Editor
Laura A. Fletcher

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For emergencies call 1-800-222-1222. Line is
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and commercial operations. Affiliated with the
University of Pittsburgh Schools of the Health
Sciences, UPMC is ranked among the nations best
hospitals, and No. 1 in Pennsylvania, by U.S. News &
World Report. For more information, visit UPMC.com.

24-hour emergency consultation, referral, and transport arrangements


SYS413370 JAB/LF 11/14 2014 UPMC

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